If your mailing address is different than your home address, enter it below:

Mailing Address:

Address Line 2:

City:

Town:

State:

Zip Code:

Other Last Names Used: (separated by commas)

Other First Names Used: (separated by commas)

*

Have you applied for a child care license, registration, or certificate from Vermont or any other state within the last five (5) years?

Yes

No

If the answer to the previous question is yes, please fill out the following:

Which State?

License/Registration Outcome:

State providers have the option to submit attendance, receive notices, and perform other provider account functions through the web. If you choose to participate, you will be assigned a username and password, which you will receive at a later date. Please indicate below your preference for participating electronically, and your e-mail address if you choose to do so.